Posts Tagged ‘Metlakatla’

What does “call” mean? Don’t look in the dictionary

March 26, 2017

Consider the places I’ve been

Then tell me, what does “call” mean?

For sometimes the word “call”

Means nothing at all

And sometimes it can make me turn green

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and short jobs in western Iowa and Alaska, I am working in Clarinda, Iowa. Any identifiable patient information has been included with permission.

People can use the same word to mean different things, and the same person can use a word at different times to mean different things.

For example, when I worked in the Indian Health Service, “call” started at 4:30PM and lasted until 8:00AM. Weekend call started on Friday afternoon and lasted till Monday morning.

In my years of private practice, it started at 5:00PM and went till 7:00AM. The doc who took Friday evening call worked the clinic on Saturday from 9:00AM till 2:00PM.  The physician with weekend call started Saturday as early as he or she wanted, rounded on the patients in the hospital, and took care of admissions till 7:00 Monday morning.  For a long time we saw the patients who came to the ER, but that faded over the years.  The on call doctor did the obstetrics over the weekend.

Call in Barrow (now called Utqiavik) never meant anything other than 12 hours, weekend, weekday, or holiday.

In Petersburg, the physician on call also covered the emergency room.

In western Nebraska, being on weekend call meant doing a Saturday clinic till noon, rounding on patients Saturday and Sunday, and admitting patients from the ER.

In Metlakatla, where we had no hospital beds, the two main ER nurses had excellent clinical skills. I could rely on them to know when I needed to come in and when I could safely wait to see the patient in the morning.

I have call this weekend, starting at 8:00AM on Thursday and going to 8:00AM on Monday. During that time, I’ll round on the hospitalized patients.  But someone else will work the Emergency Room.  If a patient needs admission, the Emergency doc does an admit note and writes admitting orders.  If a patient needs me to come in and see them before morning, they generally need to be at a larger facility.

I have had two nights of call so far. The first one passed without my phone going off, not even once.  The second time I worked steadily till 9:00PM stabilizing a very ill patient for transport.

But what does call really mean, here, this weekend?

I can tell you on Monday.

And I can guarantee it won’t mean the same thing a month from now.

First week back in Metlkatla

December 22, 2016

With parents, so strong, warm and brave

To them the praises I gave

Imagine the joys

In a room with 3 boys

And all of them stay well-behaved.

 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and a couple of assignments in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

MONDAY

Normally, I cruise right through jet lag, but with plane delays, sleep disruption on the way here shattered my usual techniques. The schedule wisely gave me Monday morning to get up to speed with the EMR, but no one to help me.   I used this system here and elsewhere in Alaska before.  Open –sourced from the Veteran’s Administration, it has functioned well for the last couple of decades.

The sun rises late and sets early here, short days mean I walk to and from work in the dark. I wake up early, more or less at the time I got up in Iowa.  But my office and the exam rooms have windows giving onto spectacular views, with evergreens and towering, snow-capped mountains.  Sometimes, during an examination, I ask patients whether they get tired of the scenery.  Uniformly, they don’t.  People move back from the cities to live here.

TUESDAY

Our clinic does a lot of treatment with nebulized albuterol, IV fluids and Zofran (ondansetron), a potent anti-vomiting drug. So far everyone needing albuterol smokes or is exposed to smoke.  Dehydration,  with the need for IV fluids, can come from a number of sources.  I get a charge when a patient feels better because of fluid replacement or breathes better because of albuterol.

Wednesday

I’ve given out a lot of Zofran since I started here three days ago; I enjoy the change on patients’ faces when the drug takes away the nausea..

Today I have call.  With the upcoming holidays and a number of permanent staff on vacation, the usual Wednesday afternoon meetings got postponed, and no one bothered to reschedule patients.  I didn’t want to face an afternoon with no work, and, as it turned out, I didn’t have to.

We have limited diagnostic and therapeutic capabilities here, and I don’t mind. With no CT, very limited lab chemistries, and no ultrasound, we send a lot of blood tests out.  If time frame permits, we make arrangements for transport by ferry for specialist consults.  But more than one person so far has required Medevac via boat to Ketchikan

THURSDAY

More permanent staffers have left on vacation. Mostly I do Urgent Care with a chance of follow-up, but sometimes I take care of people with long-term problems.

Today a family came in, both parents and three sons under the age of 10. The boys stayed well-behaved and quiet, without interruption, during the entire visit.  When not watched, the oldest took the opportunity to hug his brother.  I saw similar patterns of behavior in other families with three sons when I worked here in April: oldest hugs middle, middle hugs youngest.  At the end of the visit, I thanked the parents for the treat of caring for their children.

I didn’t say, but I wanted to: “It’s a pleasure to work in a community where families maintain such a high level of functionality.”

 

.

First day in Metlakatla

April 12, 2016

I set off in the down-pouring rain

To the clinic, a small House of Pain

I started up with a smile,

Because that’s my style

And it’s easy for me to sustain.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. After two months each in Western Nebraska and the West Coast of Alaska, I’m now in Southeast Alaska.  Any specific patient information has been included with permission.

On Sunday we took the ferry from Ketchikan to Annette Island, a ride of 45 minutes. We arrived in a pouring rain.

People call this area of Alaska the Panhandle, it juts southeast along the Pacific coast. It receives an average of over 100 inches of precipitation yearly.

About 2000 souls reside in Metlakatla, the town on the west part of the island. WWII brought an influx of defense personnel, who did not leave until late in the 20th Century; the majority of the inhabitants are Natives. As Alaska’s only Indian Reservation, license plates and driver’s licenses are optional, and ATVs run street legal.

The clinic assigned us to a cozy apartment less than a half-mile walk from the clinic, and I did my initial morning commute on foot in a torrential rain.

My first day on the job here started with morning rounds.

Talk of tides and fishing dominated the conversation before the clinical discussion. I mentioned the poster warning of paralytic fish poisoning I’d seen on the front door, and those present assured me that the problems wouldn’t start for a month or so.

The doc who had call opened the discussion with a rundown of the weekend ER patients.

I spent the morning in orientation and getting my ID badge and entry card, and I took care of four patients in the afternoon. I used RPMS, an Electronic Medical Record (EMR) system developed by the Veteran’s Administration.  Far from perfect, I find it the best one of the 9 I’ve learned in the last 14 months.

I talked to a relative of the first Native to be drafted by the NBA (that unique individual has a lot of relatives on the island).

I saw the first of what would be a string of patients with violent vomiting and diarrhea, ranging from infant to middle age. Almost certainly viral, we have no treatment aside from oral rehydration, or, in extreme cases, IV rehydration.

But we are a clinic with an ER and no hospital; we don’t keep patients overnight. I will have to weigh the risks of a boat ride if I consider sending a patient for further diagnosis or treatment.

At the end of the day, we arrived back at the apartment dripping from a walk in the driving rain.

Well, if you can’t take the rain, stay out of the Panhandle.

Ketchikan to Metlakatla

April 12, 2016

We came across on the ferry

At leisure, and then we could tarry.

Some food we bought more

With a trip to the store

And we found some good prices on dairy.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. I spent last winter in Nome, Alaska, followed by assignments in rural Iowa. The summer and fall included a medical conference in Denver, working Urgent Care in suburban Pennsylvania, and Thanksgiving in Virginia. So far this year I worked assignments in western Nebraska and southwestern Alaska; I just arrived in southeast Alaska.  Any specific patient information has been included with permission.

We took the ferry from Ketchikan to Annette Island, the only Indian Reservation in Alaska. In 1887 an Anglican missionary, motivated by doctrinal differences, led a thousand Canadian Tsimtshians on a search for a new home.  They found this island, moved legally, and in 1906 petitioned for, and received, reservation status from Congress.

Fortunate enough to have no mineral wealth that economic interests wanted to steal, they maintained their reservation more or less inviolate until WWII, when they got an air base, and a promise to build a road to the other side of the island so as to link up with the Alaska Marine Highway system. The road took eleven years to build and finished 8 years ago.

We learned these things from the Security guard who drove the 15 miles from the clinic to pick us up, and also took us on a tour of the town.

Falling timber prices shut down the logging and sawmill operations.  The salmon cannery, the casino, the school, and the clinic provide the most jobs.

We passed the gas station, the schools, the churches, but no bars or liquor stores.

Perhaps because of fewer freeze-thaw cycles, perhaps because of better maintenance, the roads lack the crater-grade potholes we find back home in the spring.

The guard helped us drag the luggage up the stairs to the apartment. We unpacked briefly.  We ate the snack that Bethany had the foresight to bring, then we walked to the grocery store.

We hadn’t expected a well-maintained, well-stocked, brightly-lit facility.  The prices, a big higher than Ketchikan’s, didn’t look so bad compared to what we’ve paid for the last two months.

Then we settled in. We tried the TV and found no service, and we had no idea whom to call about the Internet password.  We played Scrabble, ate some salmon we’d brought, and found ourselves exhausted when the sun went down.

In the same time zone, but we definitely faced jet lag.